Bladder Cancer
Epidemiology and Etiology
Bladder cancer is one of the most commonly diagnosed malignancies in the US, with 81,400 estimated cases in 2020.1 Bladder cancer is three times more common in men with a median age of 65 at diagnosis.
Common risk factors include advanced age, male sex, and cigarette smoking. Additional risk factors include pelvic radiation, prolonged use of cyclophosphamide, chronic indwelling Foley catheter, and chronic bacterial or Schistosoma haematobium infections.Pathology
Transitional cell or urothelial carcinoma is the most common histology.
Clinical Presentation
Most patients present with painless gross hematuria. Other presentations may include isolated microscopic hematuria and lower urinary tract symptoms such as frequency, urgency, and dysuria.
Diagnostic Testing
Patients with macroscopic hematuria should be evaluated with cystoscopy and CT urogram, whereas in those with asymptomatic microscopic hematuria, defined as #8805;3 red blood cells (RBCs) per high power field (HPF), the indication for cystoscopy is defined by the following risk stratification system. Patients with high risk, defined by the presence of age gt;60, gt;30 pack-year smoking history, or gt;25 RBCs per HPF on a single urinalysis should undergo cystoscopy and CT urogram. Patients with intermediate risk, defined by age 50-59 in women or 40-59 in men, 10-30 pack-year smoking history, or 11-25 RBCs per HPF should undergo cystoscopy and renal ultrasound. Patients with low risk may repeat a urinalysis in 6 months or undergo cystoscopy plus renal ultrasound. During the cystoscopy, newly identified tumors should be treated with transurethral resection of bladder tumor (TURBT), which provides diagnostic, staging and therapeutic results. An adequate TURBT should include sampling of the muscularis propria.21
Staging
In addition to TNM staging classification, bladder cancers can be broadly divided into non-muscle- invasive, muscle-invasive, and metastatic cancers, which impacts management.
For nonmetastatic tumors, the TURBT should define the depth of invasion and differentiate between non-muscle-invasive and muscle-invasive based on the invasion of the muscularis propria.TREATMENT
• Non-muscle-invasive tumors (stages 0-I) are treated with TURBT with subsequent treatment based on the risk stratification. Patients with low-risk disease, defined as a low-grade, noninvasive (Ta), #8804;3 cm solitary lesion should undergo surveillance. Patients with intermediate-risk disease may be considered for intravesical bacille Calmette-Guerin (BCG), whereas those with high-risk, defined as high-grade, carcinoma in situ with invasion of the lamina propria (T1), gt;3 cm lesion or multifocal lesions, should undergo intravesical BCG. Patients that are not candidates for cystectomy may be treated with chemoradiotherapy, radiation therapy alone, or TURBT.
• The standard treatment options for patients with metastatic disease include cisplatin plus gemcitabine
(or cisplatin plus methotrexate) with vinblastine and doxorubicin (MCAV). Other options include single-agent gemcitabine, ICIs, erdafitinib for patients with FGFR2 or FGFR3 alterations, as well as two ADCs, sacituzumab govitecan which targets TROP-2 and enfotumab vedotin which targets nectin- 4.21